The term“Sensory” has hit schools and hit them big. Many school districts are building their own motor labs complete with swings, trampolines, and squeeze machines (I can’t recall the technical term for these but that is essentially what it is). School administrators are promoting these rooms to teachers and parents with occupational therapy being highly recognized in the promotion of "sensory" within the school setting.
Yet I have felt there has been something lacking in the implementation of sensory tools and rooms that would justify pulling students from their educational curriculum to participate in "sensory" activities. I have noticed little connection between the use of these rooms and tools to research or sensory integration theory.
Students with excellent gross motor skills leave their academics in order to come to motor lab and receive “input to organize their sensory processing”, yet the people bringing them there have very little if any background in occupational therapy or sensory integration theory. I don’t believe that the needs of students should be neglected; however I do think it would be wise to pause and consider what school is for and how we can truly support our students with sensory processing difficulties in their educational needs. Sensory integration and sensory based strategies were never intended to be a "one-size fits all model". Like occupational therapy itself, sensory integration is intended to be highly individualized to the child, environment, and occupational performance.
I have to admit I have never been a big fan of sensory integration in school-based practice. I have found that implementing true sensory integration based strategies, evaluation, and therapy is difficult to do with my limited schedule and skills set. Evaluation of how children process and integrate sensations from their environment is difficult and requires specialized knowledge and training.
When evaluating sensory processing within the school based setting is important for the occupational therapist to consider more than what tool could be trialed. Assessment should also include how sensory processing difficulty is impacting functional performance beyond the apparent "sensory-related behavior". Two more questions when addressing sensory the school-based practitioner may want to ask should include: What are the demands of the classroom environment? How will the child meet the demands of given classroom activities. If the student is fidgeting frequently its important to also observe how this impacts his classroom performance and his ability to meet classroom demands. This will impact what strategies you utilize and how you go about implementing them. It is not enough to merely provide a tool based on this observed behavior as that could end up being counter productive or ineffective.
Giving the Sensory Processing Measure or Sensory Profile can provide important information; however it is also important to conduct classroom observations and other clinical observations of the child in order to truly determine what approach will be effective. Staff interviews and having classroom personnel collect data on the observable sensory-related behaviors is also necessary and can help the occupational therapist best fit their approach be considering the needs of the classroom in conjunction with the needs of the child.
I recognized my own limitations in regards to sensory integration when I recently fell into the “easy button” sensory tool approach myself. I provided a student who had a diagnosis of autism with a “chew tool” due to his teacher reported sensory needs and history of having had this particular strategy used in the past with reported success. Without having conducted an observation or worked with him directly I caved to the pressure of providing the tool on a trial basis. The student chewed so extensively that he went through three of them in a very short period with little change in his maladaptive behaviors (i.e. his grabbing and pulling hair, pinching staff, and squeezing faces). I should note that he had access to a variety of sensory-based tools including a therapy ball, headphones, weighted vest, thera-band, and multiple squeezable fidgets. I decided that prior to providing the 4th "chew tool" I would conduct classroom observations to determine what was impacting his classroom performance and gain a better understanding of how his sensory processing was preventing him from meeting the demands of his environment and expected task performance.
Once I put on my occupational therapy hat and observed the student in his classroom a series of "Aha" moments began to occur to me!The first thing I decided to build a profile of the student. He was a student with Autism who demonstrated behaviors related to a very high excitement level I would even say his behaviors appeared anxious and ones of discomfort (he was observed to grimace and squint frequently). He seemed highly sensitive to every bit of stimuli in his environment. He also demonstrated significant difficulty communicating his needs. Communication appeared to be slow, and in short phrases and words. This student also appeared to scan the room by moving his entire head and body versus utilizing scanning and tracking skills.
The second part of classroom observation included observing during non-preferred activities during which his maladaptive behavior was more likely to occur. I then observed two separate moments when the maladaptive behavior occurred. Both occurred during the reading and writing center on two separate observations. Prior to both behavior incidents another student had acted out by falling onto the floor and yelling at the same center. It should also be noted that I had reviewed his previous assessments and reading and writing is a largely non-preferred task for this student as well as his biggest area of deficit.
The third part of the evaluation was how the student coped or attempted to cope with the environment and task demands given his sensory processing difficulties. Prior to the behavior incident the student attempted move away from his acting out classmate and the teacher had prevented him from leaving. She required that he first told her what he wanted before he was allowed to get up and access his headphone. Being that he was already distressed he was not able to communicate this and eventually grabbed her hair and face. In observing these moments it became clearer that a "chew tool" was not going to be the answer.
What the teacher had told me was sensory based due to the lack of tools (i.e. she wanted a trampoline in her classroom and more chew tools) was in fact sensory based; however it would not have been made better with use of those tools. I also discovered after interviewing staff that this student had been moved from his previous years’ class into his current placement. This classroom had new staff, teacher, peers, higher demands and was within a very different environmental structure with less freedom or free time than he had been used to.
To top it off, he had been in his previous class for three years. The teacher and aids knew how to anticipate his needs and scaffold his environment in order to prevent these behaviors; therefore his behaviors and previous sensory seeking had nearly disappeared before this change. Given this student's high sensory sensitivity he required more support to reduce sensory input during challenging tasks, incorporating more sensory breaks where he could escape or reduce the sensory input he was receiving as well as highly structuring his classroom tasks experiences. Based on my observations and interviews we were able to collaboratively come up with a plan to address this student’s needs.
Conducting these observations is imperative to appropriately utilizing the models in sensory integration and it can be difficult to adequately perform these observations and interviews but I would argue that it is also necessary in order to provide sensory integration based strategies within the classroom setting. Luckily I work in a school district who is interested in keeping our caseloads manageable so that I have the time to perform these very important job duties. I have worked in other districts where I was fighting to just keep afloat so observations such as these were not easily conducted. It is easy to become complacent or so overwhelmed that we end up offering sensory-based tools as easy buttons, but we need to remember that that this is not sensory integration and often times it is also not evidence-based.
I'm not trying to downplay the power of fidgets or wiggle seats and I'm definitely not advocating for the removal of these tools, but I am encouraging us as occupational therapists working in schools to remember that sensory integration theory is different from the tools. It is out job as the occupational therapist to assess what the students needs are and how that is impacting classroom performance.
When we look to simplify sensory into a tool or strategy it can lead to a wider misunderstanding and misinterpretation of sensory integration. Like sensory integration itself, occupational therapy is difficult to describe and by its very nature complex in its evaluation and implementation. I say we embrace this complexity in both occupational therapy as well as sensory. We need to do the work of advocating for sensory integration in schools by embracing and teaching the complex nature of both sensory integration and school-based occupational therapy to the school personnel, parents, and administrators of the schools we service.
What are you doing to promote appropriate use of sensory integration based tools within the classroom? Do you feel you have adequate knowledge and skills to tackle student needs in this area? What would you like more training in?
For more reading on use of sensory integration in school settings check out the links to references below:
Choosing Wisely Q & A: Renee Watling on Sensory Intervention and Assessment
Building Competency in SI: Evidence-based Guidelines for Occupational Therapists using Ayers Sensory Integration
Occupational Therapy for Children and Youth Using Sensory Integration Theory and Methods in School-based Practice. (2015). American Journal of Occupational Therapy, 69, 1-20. Retrieved November 14, 2018, from https://ajot.aota.org/article.aspx?articleid=2442686.
Thank you for reading! When we all work together we can promote occupational therapy in schools as well as throughout our communities! :)